37例肝囊型包虫破入胆道诊治分析
摘要: 目的: 探讨肝囊型包虫破入胆道的诊断和治疗经验。方法: 对37例肝囊型包虫破入胆道患者的临床资料进行回顾性分析，采用腹部超声(SUG)、CT、核磁共振胆胰管造影(MRCP)、内镜逆行胰胆管造影(ERCP)分别检查37、22、12、4例,36例患者施行肝包虫内囊摘除及残腔引流术,其中31例行胆总管探查“T”型管引流术，4例经胆囊管置引流管胆总管减压，1例行Rouxeny胆总管空肠吻合术, 1例内囊摘除术后患者内镜十二指肠乳头切开清理胆道引流术。结果：SUG、CT、MRCP均能准确诊断包虫囊肿，对胆道扩张的诊断率分别为67.6%、77.3%、100.0%，ERCP对胆道扩张、胆总管内包虫内囊和(或)子囊碎片及包虫囊肿与胆管相交通的诊断率均为100.0%。术中胆瘘口缝合的19例患者中2例出现术后残腔胆瘘,而未缝合的17例中8例出现胆瘘, 缝合者平均住院10.9 d, 未缝合者平均住院18 d (P<0.05)。结论: MRCP检查对高度可疑肝囊型包虫破入胆道患者具有诊断准确和无创等优点,ERCP不仅对该病有确诊意义，而且可对该病术后并发症实施有效的治疗。缝合胆瘘、胆道减压是治疗肝囊型包虫破入胆道的简单、安全、有效且并发症少的方法,而术中胆道造影和胆道注射亚甲蓝是发现胆瘘口的有效的手段。
关键词: 破入胆道；囊型包虫病；肝脏
Diagnosis and treatment of 37 patients with intrabiliary rupture
of hepatic hydatid cyst
Tuerganaili Aji, SHAO Yingmei, ZHAO Jinming, et al
(Hepatobiliary & Hepatic Hydatid Department of Digestive and Vascular Surgery Centre,
First Teaching Hospital, Xinjiang Medical University, Urumqi 830054, China)
Abstract: Objective: To evaluate the diagnosis and treatment of the rupture of hepatic hydatid cyst into bilary duct. Methods: Thirtyseven patients with intrabiliary rupture of hepatic hydatid cysts were retrospectively reviewed. Results: The diagnosis of intrabiliary rupture may be difficult on ultrasounography (USG) and CT, sensitivity rates of USG and CT were 67.6% and 77.3% respectively. MRCP is an effective, noninvasive and useful diagnostic tool in difficult cases; ERCP is the gold standard in confirming diagnosis. Partial cystectomy and cholecystectomy in 36 patients, common bile duct exploration were performed in 31 patients. In 19 patients, the biliary duct within the cyst cavity was sutured. Intraoperative cholangiography was performed in 8 patients and diluted methylene blue was delivered through bile duct into the biliary system in 5 patients. Ttube was inserted after the biliary tract content was thought to have been totally cleaned out in 31 patients, inserted a Foley catheter into the biliary tree through the choledochotomy in 4 patients and a Rouxeny choledochojejunostomy was performed in one patient. External biliary fistula developed in two patients in sutured group and in eight patients in nonsutured group. Hospitalization time was 10.9 days (ranging from 9 to 13 days) in the sutured group, but it was 18 days (ranging from 14 to 27 days) in the nonsutured group (P<0.05). One postoperative patient with highoutput biliary fistulae was successfully treated by ERCP and sphincterotomy. There was no mortality. Conclusions: MRCP is an effective, noninvasive and useful diagnostic tool; ERCP is not only the gold standard in confirming intrabiliary rupture of liver cystic hydatid disease, but also an effective technique for treating postoperative extended external biliary fistula. This study indicates that suture of the communication and biliary decompression are effective procedures with low morbidity and mortality rate.Intraoperative cholangiography or deliver methylene blue through bile duct into the biliary system is very useful for finding the biliary fistula.
Key words: intrabiliary rupture; hepatic hydatidcyst; hepatic
肝囊型包虫病(hepatic hydatid disease, HHD)是一种流行于畜牧业区的常见人体寄生虫病,其在体内生长过程中可引发多种并发症,肝包虫囊肿破入胆道是较为常见的严重并发症之一,其发生率约在3%～17%[1,2],临床症状主要有右上腹部疼痛、黄疸、寒战伴发热等,如不及时处理,可能导致急性梗阻性化脓性胆管炎甚至危及生命的严重后果[3]。本文对1995～2006年我院收治的37例肝包虫囊肿破入胆道患者的临床资料进行回顾性分析,现报道如下。
1资料与方法
1.1临床资料我院1995～2006年手术治疗肝囊型包虫1 245例,其中37例(2.97%)为肝包虫囊肿破入胆道者,男性20例，女性17例，男∶女为1.18∶1，年龄10～75岁，平均31.2岁。37例患者共有47个肝包虫囊肿，其中30例为单发，7例为双发或多发；囊肿位于肝右叶24例(64.86%)，肝左叶10例(27.03%),左、右肝叶均有肝包虫囊肿3例(8.11%)；WHO/IWGE肝囊型包虫标准化分型：多子囊型(CE2)占63.8 % ,内囊塌陷型(CE3)占27.3%；囊肿直径5～20 cm,平均(13.2±0.5) cm,>10 cm者30例(81.08%)。右上腹或上腹疼痛不适36例,黄疸29例，寒战和(或)发热18例,肝大14例,肝区触痛或叩击痛10例，恶心、呕吐9例。
1.2方法术前37例患者均行血常规、肝功能、血清学免疫、胸片、腹部超声(USG)检查,其中22例行CT检查,12例行核磁共振胆胰管造影(MRCP)、4例行内镜逆行胰胆管造影(ERCP),8例术中行胆道造影。36例患者施行肝包虫内囊摘除残腔外引流术,其中26例穿刺抽出胆汁,7例残腔内发现胆瘘口并缝合，术中胆道造影8例，经胆囊管注射亚甲蓝5例,其中12例明确找出胆瘘口并缝合, 其余17例因解剖位置深在或无法暴露等原因未找到胆瘘口。36例中31例行胆总管探查清除胆道“T”型管引流术,其中11例术中胆道镜清除胆道，4例经胆囊管置引流管胆道减压,1例行Rouxeny胆总管空肠吻合术。1例在外院施行肝包虫内囊摘除术后出现严重残腔胆瘘(700 ml/d)，施行内镜十二指肠乳头切开清理胆道并引流术。
1.3统计学处理平均住院日的比较采用t检验，术后胆瘘发生率的比较采用χ2检验,检验水准α=0.05。
2结果
2.1不同影像学方法对肝囊型包虫破入胆道的诊断率USG和CT诊断肝囊型包虫准确率达100%,胆道扩张的诊断率分别为67.6%、77.3%，而MRCP和ERCP对胆道扩张的诊断率均达100.0%(表1)。表1不同影像学方法肝包虫破入胆道的诊断率的比较检查方法
2.2治疗结果19例胆瘘口缝合患者中2例(10.53%)出现术后残腔胆瘘,而未缝合的17例中8例(47.1%)出现残腔胆瘘(P<0.01)，其中3例是严重胆瘘(每日胆汁引流量>250 ml),缝合患者住院9～13 d 平均 10.9 d, 未缝合者住院14～27 d，平均18 d (P<0.05)。1例在外院施行肝包虫内囊摘除术后出现严重残腔胆瘘(700 ml/d)患者施行内镜十二指肠乳头切开清理胆道并引流术后26 d胆瘘愈合拔除残腔引流管。
3讨论
3.1肝囊型包虫破入胆道的形成机制肝囊型包虫囊肿破入胆管是由于包虫囊肿呈膨胀性生长，刺激周围肝组织,形成厚实的纤维结缔组织外囊,外囊中常包含有肝胆管，这些胆管因受挤压发生扭曲、萎缩和变形，进而引发胆汁淤滞和渗漏,甚至在外力的作用下破溃开口于囊壁上,形成胆管与包虫囊的瘘，或包虫在生长过程中对相邻胆管产生压迫，致胆管壁缺血坏死部分内囊壁随囊内压力增高突出于胆管,并在胆汁的作用下发生破溃，因胆道与包虫囊肿之间有压力差,破入胆道后囊皮、子囊等进入胆道引起梗阻[4]。Tsitouridis 等[5]认为肝包虫破入胆道的程度与包虫体积大小、包虫囊肿压力的高低、包虫囊肿分型及破口的大小有关。
3.2肝囊型包虫破入胆道的诊断肝囊型包虫病根据患者流行病史、症状、体征、血清免疫及影像学检查较容易诊断。USG和CT检查是肝囊型包虫病的准确、有效的诊断方法，但对于包虫囊肿破入胆道的诊断较困难，而在包虫病流行区患者如出现发热、黄疸、右上腹疼痛、肝脏肿大或触及肝脏包块、血清免疫试验阳性、肝内的囊性占位性病变和胆总管扩张等症状和体征，应考虑可能有肝包虫囊肿破入胆道。USG和CT检查如检出包虫囊肿与胆管的交通口即可确诊。本组中USG和CT检查检出包虫囊肿与胆管相交通率分别为21.6%和36.4%，但大多数患者检出胆总管增粗或于增粗的胆总管内见短线状、条带状或小光环状回声等间接征象,结合病史、临床表现及免疫学检查,可以诊断本病。ERCP是有效、准确诊断该病的方法,其对包虫囊肿与胆管的交通口后增粗的胆总管内包虫内囊和(或)子囊碎片的准确率可达86%～100%[6]。与ERCP相比，MRCP具有无创的优点，准确度和灵敏度达75%～100%[7]。但仍有部分患者需术中确诊。
3.3肝包虫破入胆道的治疗肝囊型包虫囊肿破入胆道是肝囊型包虫病的严重并发症之一,可引起胆道梗阻、急性化脓性胆管炎、肝脓肿、急性胰腺炎等严重后果，一旦确诊，手术是首选的治疗方法。手术的原则是清除肝包虫内囊和(或)子囊 ；酌情处理包虫外囊残腔,同时探查胆总管并实施有效地引流。摘除内囊后探查残腔时,要尽可能找到与残腔相通的胆道,胆道造影是简单、可行的方法。用丝线缝扎破损处,可以有效地的缩短患者的带管时间及预防术后胆瘘的发生，本组残腔内发现胆瘘口7例,术中胆道造影和经胆囊管胆道注射亚甲蓝明确胆瘘口12例,19例均给予缝合胆瘘口,其中只有2例(10.5%)术后出现残腔胆瘘, 而未缝合者17例中出现8例(47.1%) (P<0.01)，其中3例是严重胆瘘，每日胆汁引流量>250 ml，最长带残腔引流管时间为4个月。术中尽可能缩小残腔,若引流管无胆汁及液体流出,应及早拔除,以防逆行感染。肝包虫外囊残腔的处理有多种方法,本组36例均采用置管外引流。手术应探查胆总管并彻底清除包虫内囊、子囊及碎屑，术中胆道镜清除是有效的方法。胆道减压是保证胆管破口及包虫残腔闭合的必要条件,胆总管内置T型引流管为最常用的方法,操作简单,效果较好。本组36例中有31例采用此法,效果良好。4例胆总管内没有包虫囊内容物或经胆瘘口清除胆道的患者，经胆囊管置引流胆道减压，此方法操作简单，创伤小，又能达到胆道减压的目的。ERCP不仅对该病的确诊有一定意义,而且可对该病术后残腔严重胆瘘并发症实施有效的治疗，缝合胆瘘、胆总管减压是治疗肝囊型包虫破入胆道的合理、简单、安全且并发症少的方法,而术中胆道造影和胆道注射亚甲蓝是发现胆瘘口的简单、可行的手段。
参考文献:
[1]Paksoy M, Karahasanoglu T, Carkman S, et al. Rupture of the hydatid disease of the liver into the biliary tracts[J]. Dig Surg, 1998, 15:2529.
[2]Zaouche A, Haouet K, Jouini M, et al. Management of liver hydatid cysts with a large biliocystic fistula: multicenter retrospective study [J]. World J Surg, 2001, 25:2839.
[3]Bedrail A, Sakrak O, Sozuer EM, et al. Surgical management of spontaneous intrabiliary rupture of hydatid liver cysts[J]. Surg Today, 2002, 32: 594597.
[4]Becker K, Frieling T, Salch A, et al. Resolution of hydatid liver cyst by spontaneous rupture into the biliary tract[J]. Hepatology, 1997, 26:14081412.
[5]Tsitouridis J, Kouklakis G, Tsitouridis K, et al. Intrabiliary obstruction due to ruptured hepatic hydatid cyst: evaluation with computed tomography and magnetic resonance imaging [J]. Dig Endosc, 2001, 13:712.
[6]Bilsel Y, Bulut T, Yamaner S, et al. ERCP in the diagnosis and management of complications after surgery for hepatic echinococcosis[J]. Gastrointest Endosc, 2003,57: 210213.
[7]Laghi A, Teggi A, Pavone P, et al. Intrabiliary rupture of hepatic hydatid cysts: diagnosis by use of magnetic resonance cholangiography [J]. Clin Infect Dis, 1998, 26:14671468.
(新疆医科大学第一附属医院消化血管外科中心肝胆包虫外科, 新疆乌鲁木齐830054), http://www.100md.com(吐尔干艾力·阿吉 邵英梅, 赵晋明, 温浩)
关键词: 破入胆道；囊型包虫病；肝脏
Diagnosis and treatment of 37 patients with intrabiliary rupture
of hepatic hydatid cyst
Tuerganaili Aji, SHAO Yingmei, ZHAO Jinming, et al
(Hepatobiliary & Hepatic Hydatid Department of Digestive and Vascular Surgery Centre,
First Teaching Hospital, Xinjiang Medical University, Urumqi 830054, China)
Abstract: Objective: To evaluate the diagnosis and treatment of the rupture of hepatic hydatid cyst into bilary duct. Methods: Thirtyseven patients with intrabiliary rupture of hepatic hydatid cysts were retrospectively reviewed. Results: The diagnosis of intrabiliary rupture may be difficult on ultrasounography (USG) and CT, sensitivity rates of USG and CT were 67.6% and 77.3% respectively. MRCP is an effective, noninvasive and useful diagnostic tool in difficult cases; ERCP is the gold standard in confirming diagnosis. Partial cystectomy and cholecystectomy in 36 patients, common bile duct exploration were performed in 31 patients. In 19 patients, the biliary duct within the cyst cavity was sutured. Intraoperative cholangiography was performed in 8 patients and diluted methylene blue was delivered through bile duct into the biliary system in 5 patients. Ttube was inserted after the biliary tract content was thought to have been totally cleaned out in 31 patients, inserted a Foley catheter into the biliary tree through the choledochotomy in 4 patients and a Rouxeny choledochojejunostomy was performed in one patient. External biliary fistula developed in two patients in sutured group and in eight patients in nonsutured group. Hospitalization time was 10.9 days (ranging from 9 to 13 days) in the sutured group, but it was 18 days (ranging from 14 to 27 days) in the nonsutured group (P<0.05). One postoperative patient with highoutput biliary fistulae was successfully treated by ERCP and sphincterotomy. There was no mortality. Conclusions: MRCP is an effective, noninvasive and useful diagnostic tool; ERCP is not only the gold standard in confirming intrabiliary rupture of liver cystic hydatid disease, but also an effective technique for treating postoperative extended external biliary fistula. This study indicates that suture of the communication and biliary decompression are effective procedures with low morbidity and mortality rate.Intraoperative cholangiography or deliver methylene blue through bile duct into the biliary system is very useful for finding the biliary fistula.
Key words: intrabiliary rupture; hepatic hydatidcyst; hepatic
肝囊型包虫病(hepatic hydatid disease, HHD)是一种流行于畜牧业区的常见人体寄生虫病,其在体内生长过程中可引发多种并发症,肝包虫囊肿破入胆道是较为常见的严重并发症之一,其发生率约在3%～17%[1,2],临床症状主要有右上腹部疼痛、黄疸、寒战伴发热等,如不及时处理,可能导致急性梗阻性化脓性胆管炎甚至危及生命的严重后果[3]。本文对1995～2006年我院收治的37例肝包虫囊肿破入胆道患者的临床资料进行回顾性分析,现报道如下。
1资料与方法
1.1临床资料我院1995～2006年手术治疗肝囊型包虫1 245例,其中37例(2.97%)为肝包虫囊肿破入胆道者,男性20例，女性17例，男∶女为1.18∶1，年龄10～75岁，平均31.2岁。37例患者共有47个肝包虫囊肿，其中30例为单发，7例为双发或多发；囊肿位于肝右叶24例(64.86%)，肝左叶10例(27.03%),左、右肝叶均有肝包虫囊肿3例(8.11%)；WHO/IWGE肝囊型包虫标准化分型：多子囊型(CE2)占63.8 % ,内囊塌陷型(CE3)占27.3%；囊肿直径5～20 cm,平均(13.2±0.5) cm,>10 cm者30例(81.08%)。右上腹或上腹疼痛不适36例,黄疸29例，寒战和(或)发热18例,肝大14例,肝区触痛或叩击痛10例，恶心、呕吐9例。
1.2方法术前37例患者均行血常规、肝功能、血清学免疫、胸片、腹部超声(USG)检查,其中22例行CT检查,12例行核磁共振胆胰管造影(MRCP)、4例行内镜逆行胰胆管造影(ERCP),8例术中行胆道造影。36例患者施行肝包虫内囊摘除残腔外引流术,其中26例穿刺抽出胆汁,7例残腔内发现胆瘘口并缝合，术中胆道造影8例，经胆囊管注射亚甲蓝5例,其中12例明确找出胆瘘口并缝合, 其余17例因解剖位置深在或无法暴露等原因未找到胆瘘口。36例中31例行胆总管探查清除胆道“T”型管引流术,其中11例术中胆道镜清除胆道，4例经胆囊管置引流管胆道减压,1例行Rouxeny胆总管空肠吻合术。1例在外院施行肝包虫内囊摘除术后出现严重残腔胆瘘(700 ml/d)，施行内镜十二指肠乳头切开清理胆道并引流术。
1.3统计学处理平均住院日的比较采用t检验，术后胆瘘发生率的比较采用χ2检验,检验水准α=0.05。
2结果
2.1不同影像学方法对肝囊型包虫破入胆道的诊断率USG和CT诊断肝囊型包虫准确率达100%,胆道扩张的诊断率分别为67.6%、77.3%，而MRCP和ERCP对胆道扩张的诊断率均达100.0%(表1)。表1不同影像学方法肝包虫破入胆道的诊断率的比较检查方法
2.2治疗结果19例胆瘘口缝合患者中2例(10.53%)出现术后残腔胆瘘,而未缝合的17例中8例(47.1%)出现残腔胆瘘(P<0.01)，其中3例是严重胆瘘(每日胆汁引流量>250 ml),缝合患者住院9～13 d 平均 10.9 d, 未缝合者住院14～27 d，平均18 d (P<0.05)。1例在外院施行肝包虫内囊摘除术后出现严重残腔胆瘘(700 ml/d)患者施行内镜十二指肠乳头切开清理胆道并引流术后26 d胆瘘愈合拔除残腔引流管。
3讨论
3.1肝囊型包虫破入胆道的形成机制肝囊型包虫囊肿破入胆管是由于包虫囊肿呈膨胀性生长，刺激周围肝组织,形成厚实的纤维结缔组织外囊,外囊中常包含有肝胆管，这些胆管因受挤压发生扭曲、萎缩和变形，进而引发胆汁淤滞和渗漏,甚至在外力的作用下破溃开口于囊壁上,形成胆管与包虫囊的瘘，或包虫在生长过程中对相邻胆管产生压迫，致胆管壁缺血坏死部分内囊壁随囊内压力增高突出于胆管,并在胆汁的作用下发生破溃，因胆道与包虫囊肿之间有压力差,破入胆道后囊皮、子囊等进入胆道引起梗阻[4]。Tsitouridis 等[5]认为肝包虫破入胆道的程度与包虫体积大小、包虫囊肿压力的高低、包虫囊肿分型及破口的大小有关。
3.2肝囊型包虫破入胆道的诊断肝囊型包虫病根据患者流行病史、症状、体征、血清免疫及影像学检查较容易诊断。USG和CT检查是肝囊型包虫病的准确、有效的诊断方法，但对于包虫囊肿破入胆道的诊断较困难，而在包虫病流行区患者如出现发热、黄疸、右上腹疼痛、肝脏肿大或触及肝脏包块、血清免疫试验阳性、肝内的囊性占位性病变和胆总管扩张等症状和体征，应考虑可能有肝包虫囊肿破入胆道。USG和CT检查如检出包虫囊肿与胆管的交通口即可确诊。本组中USG和CT检查检出包虫囊肿与胆管相交通率分别为21.6%和36.4%，但大多数患者检出胆总管增粗或于增粗的胆总管内见短线状、条带状或小光环状回声等间接征象,结合病史、临床表现及免疫学检查,可以诊断本病。ERCP是有效、准确诊断该病的方法,其对包虫囊肿与胆管的交通口后增粗的胆总管内包虫内囊和(或)子囊碎片的准确率可达86%～100%[6]。与ERCP相比，MRCP具有无创的优点，准确度和灵敏度达75%～100%[7]。但仍有部分患者需术中确诊。
3.3肝包虫破入胆道的治疗肝囊型包虫囊肿破入胆道是肝囊型包虫病的严重并发症之一,可引起胆道梗阻、急性化脓性胆管炎、肝脓肿、急性胰腺炎等严重后果，一旦确诊，手术是首选的治疗方法。手术的原则是清除肝包虫内囊和(或)子囊 ；酌情处理包虫外囊残腔,同时探查胆总管并实施有效地引流。摘除内囊后探查残腔时,要尽可能找到与残腔相通的胆道,胆道造影是简单、可行的方法。用丝线缝扎破损处,可以有效地的缩短患者的带管时间及预防术后胆瘘的发生，本组残腔内发现胆瘘口7例,术中胆道造影和经胆囊管胆道注射亚甲蓝明确胆瘘口12例,19例均给予缝合胆瘘口,其中只有2例(10.5%)术后出现残腔胆瘘, 而未缝合者17例中出现8例(47.1%) (P<0.01)，其中3例是严重胆瘘，每日胆汁引流量>250 ml，最长带残腔引流管时间为4个月。术中尽可能缩小残腔,若引流管无胆汁及液体流出,应及早拔除,以防逆行感染。肝包虫外囊残腔的处理有多种方法,本组36例均采用置管外引流。手术应探查胆总管并彻底清除包虫内囊、子囊及碎屑，术中胆道镜清除是有效的方法。胆道减压是保证胆管破口及包虫残腔闭合的必要条件,胆总管内置T型引流管为最常用的方法,操作简单,效果较好。本组36例中有31例采用此法,效果良好。4例胆总管内没有包虫囊内容物或经胆瘘口清除胆道的患者，经胆囊管置引流胆道减压，此方法操作简单，创伤小，又能达到胆道减压的目的。ERCP不仅对该病的确诊有一定意义,而且可对该病术后残腔严重胆瘘并发症实施有效的治疗，缝合胆瘘、胆总管减压是治疗肝囊型包虫破入胆道的合理、简单、安全且并发症少的方法,而术中胆道造影和胆道注射亚甲蓝是发现胆瘘口的简单、可行的手段。
参考文献:
[1]Paksoy M, Karahasanoglu T, Carkman S, et al. Rupture of the hydatid disease of the liver into the biliary tracts[J]. Dig Surg, 1998, 15:2529.
[2]Zaouche A, Haouet K, Jouini M, et al. Management of liver hydatid cysts with a large biliocystic fistula: multicenter retrospective study [J]. World J Surg, 2001, 25:2839.
[3]Bedrail A, Sakrak O, Sozuer EM, et al. Surgical management of spontaneous intrabiliary rupture of hydatid liver cysts[J]. Surg Today, 2002, 32: 594597.
[4]Becker K, Frieling T, Salch A, et al. Resolution of hydatid liver cyst by spontaneous rupture into the biliary tract[J]. Hepatology, 1997, 26:14081412.
[5]Tsitouridis J, Kouklakis G, Tsitouridis K, et al. Intrabiliary obstruction due to ruptured hepatic hydatid cyst: evaluation with computed tomography and magnetic resonance imaging [J]. Dig Endosc, 2001, 13:712.
[6]Bilsel Y, Bulut T, Yamaner S, et al. ERCP in the diagnosis and management of complications after surgery for hepatic echinococcosis[J]. Gastrointest Endosc, 2003,57: 210213.
[7]Laghi A, Teggi A, Pavone P, et al. Intrabiliary rupture of hepatic hydatid cysts: diagnosis by use of magnetic resonance cholangiography [J]. Clin Infect Dis, 1998, 26:14671468.
(新疆医科大学第一附属医院消化血管外科中心肝胆包虫外科, 新疆乌鲁木齐830054), http://www.100md.com(吐尔干艾力·阿吉 邵英梅, 赵晋明, 温浩)